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eLetters

831 e-Letters

Dr. Basu et al. make an interesting observation: if you kick the dog,
eventually he will bite the mailman.
How is it we think we can treat the workers without compassion or empathy
while expecting them to treat the patients with these same virtues, ones
we don't practice?

This article and an ever-expanding body of literature make it clear:
we must treat our staff in the same way we expect them to treat patients....

Dr. Basu et al. make an interesting observation: if you kick the dog,
eventually he will bite the mailman.
How is it we think we can treat the workers without compassion or empathy
while expecting them to treat the patients with these same virtues, ones
we don't practice?

This article and an ever-expanding body of literature make it clear:
we must treat our staff in the same way we expect them to treat patients.

Conflict of Interest:

Walker et al. report the first economic analysis of the cost of
training medical scribes (1). The concept of the medical scribe has been
around for at least 4 decades (2), but with the recent advent of the
electronic medical record (EMR), especially in the US, there has been a
rapid increase in the use of scribes, particularly in emergency
departments (3). The ongoing exponential growth in the use of scribes has
been re...

Walker et al. report the first economic analysis of the cost of
training medical scribes (1). The concept of the medical scribe has been
around for at least 4 decades (2), but with the recent advent of the
electronic medical record (EMR), especially in the US, there has been a
rapid increase in the use of scribes, particularly in emergency
departments (3). The ongoing exponential growth in the use of scribes has
been referred to as the "great scribe experiment" (4). Currently 1 in 5
practices with an EMR uses scribes (4). The data so far suggests that
scribes increase physician productivity and revenue as well as both
patient and physician satisfaction (3,5).

Two approaches to training medical scribes have been described:
teaching existing medical personal to perform scribing duties, or bringing
on new personnel entirely devoted to scribing. The medical scribe field,
as well as Walker et al., are now moving towards the later method, which
generally attracts students and recent college graduates looking to obtain
medical knowledge and experience before moving on to additional training
in the medical field, such as medical or physician assistant school. While
the later method has its advantages, it leads to frequent turnover and
thus the need for near-continuous training of new scribes, which is why is
it critical to evaluate the scribe training process. Walker et al. have
made an important contribution in describing the start up cost of a scribe
program, but the costs of maintaining an ongoing program are equally, if
not more, important.

In order to bring in medical scribes, hospitals or medical groups
generally take one of two approaches. They either contract with existing
outside scribe companies (ie. ScribeAmerica, PhysAssist, etc.), or they
build an in-house scribe program from the ground up, similar to the
process reported by Walker et al. The former approach may be more
expedient and even cost effective in the short term, however it is unclear
whether it would be as beneficial in the long term and is not an option
for every practice or department, particularly those in rural areas.
Despite the start-up costs, the later approach is arguably preferable as
it allows for more flexibility and customization of the scribes' duties to
fit the needs of the practice or department. Further research should be
directed towards understanding the costs of maintaining an existing,
mature 'homegrown' scribe program as compared to the costs of a contract
with an existing major scribe company. This would not only provide
direction for practices looking to bring on medical scribes, but also
inform their decision on whether to train their own scribes or outsource
the training to a major existing company.

Conflict of Interest:

The reported algorithm for diagnosis and exclusion of PE using Wells
score < 2 plus negative d-dimer to indicate the patient does not
require further imaging is a validated pathway. However, d-dimer
specificity is low resulting in large numbers of patients who are low-risk
for PE still requiring CTPA or a ventilation-perfusion scan. The aim of
recent diagnostic studies, including this study reported by Theunissen JMG
e...

The reported algorithm for diagnosis and exclusion of PE using Wells
score < 2 plus negative d-dimer to indicate the patient does not
require further imaging is a validated pathway. However, d-dimer
specificity is low resulting in large numbers of patients who are low-risk
for PE still requiring CTPA or a ventilation-perfusion scan. The aim of
recent diagnostic studies, including this study reported by Theunissen JMG
et al, is to use alternative diagnostic strategies to reduce the number of
patients requiring further imaging. This would reduce harm secondary to
contrast enhanced CT scanning (with a 10% false positive rate);
anticoagulation (especially for sub-segmental PE for which there remains
considerable doubt about the necessity for treatment); and ED and
radiology department crowding.

PERC is an assessment of a threshold of pre-test probability for PE
below which testing for and/or treating the disease results in greater
potential harm than benefit. This threshold is set at approximately 2%.
PERC has only been validated in a population of patients with a low pre-
test probability as determined by clinical gestalt. This retrospective
cohort study has shown that the use of PERC outside its validated
indications even as a sequential investigation with the Wells score
results in 2 outcomes - 1 potential and 1 certain

1.Specificity and sensitivity may be reduced compared to the standard
algorithm though the sample size is too small to draw significant
conclusions
2.Rates of diagnostic imaging will rise significantly. 79% of patients
with a Wells score <2 had a PERC >0 which would have required 203
extra imaging procedures in 377 patients. This would almost certainly
increase the immediate adverse event rate defined as secondary outcomes in
the paper in addition to the unquantified risk of increased radiation
exposure.

Use of clinical gestalt, PERC score of 0, Wells score <2 and a
negative d-dimer in a sequential manner to reduce the pre-test probability
to below the threshold for mandatory imaging would seem to be the way
forward in ensuring accurate diagnosis without the risks of overtreatment
and imaging. We suggest this diagnostic strategy should be urgently
evaluated.

Conflict of Interest:

As authors of a previous report about serious injuries that occurred
during an extreme sports obstacle course in the U.S. (1), we read with
interest the article by Alana Hawley, etal describing injury and illness
outcomes in a series of Canadian obstacle course events. (2) In this
Canadian study a small percentage of participants presented to onsite
medial services; the majority of complaints were minor and musculoskele...

As authors of a previous report about serious injuries that occurred
during an extreme sports obstacle course in the U.S. (1), we read with
interest the article by Alana Hawley, etal describing injury and illness
outcomes in a series of Canadian obstacle course events. (2) In this
Canadian study a small percentage of participants presented to onsite
medial services; the majority of complaints were minor and musculoskeletal
in nature. Only 2% of those treated were transferred to hospital through
EMS which is consistent with other types of mass gathering events. This
is in sharp contrast to our report in which over 100 EMS (advanced life
support calls) were activated on a single race. Social media drives
continued interest in these outcomes, and as authors, we were surprised by
the robust response of interest by a variety of media outlets in our 2014
manuscript. Particularly as these events become more popular
internationally, we just ask participants and readers to exercise caution
before they are left with the impression that these events are safe. Other
than the identified limitations that the Dr Hawley and her study team
expresses, it should be noted that they studied ONLY Mud Hero obstacle
courses. According to the Mud Hero frequently asked questions, (3) the
obstacles in these races have both hard and easy options and they do not
expose their participants to barbed wire, ice baths, or electric shocks.
The electrical shock injuries were the most severe type (myocarditis,
cerebrovascular accident) that we reported in our study. Ideally those in
the medical profession preparing for an event in their area would
determine the type of obstacles that will be used in the race, and
organize the appropriate EMS support. Likewise, participants preparing
for obstacle races should recognize the potential for increased personal
risk in those that have more dangerous obstacles (such as electrical
shocks).
(1) Greenberg MR, Kim PH, Duprey RT, etal. Unique obstacle race injuries
at an extreme sports event: a case series. Ann Emerg Med. 2014;63:361-6.
(2) Hawley A, Mercuri M, Hogg K, Hanel E. Obstacle Course Runs: Review of
Acquired injuries and illnesses at a Series of Canadian events (RACE)
Emerg Med J (online ahead of print) 9/15/2016
(3) Mud Hero Frequently Asked Questions. http://www.mudhero.com/en/faqs/
Accessed 09/20/2016

Conflict of Interest:

We agree that as a retrospective study that compares head injured
patients presenting within and after 24 hours of injury that have
undergone CT imaging our study does have limitations. However, there are
currently few data to guide clinicians in this area. We found only 2
other retrospective cohort studies and an abstract that assessed such
patients in a recently pu...

We agree that as a retrospective study that compares head injured
patients presenting within and after 24 hours of injury that have
undergone CT imaging our study does have limitations. However, there are
currently few data to guide clinicians in this area. We found only 2
other retrospective cohort studies and an abstract that assessed such
patients in a recently published systematic review {1}. Our study is the
first to directly compare patients presenting late after injury with those
who don't, to our knowledge, and includes novel findings.

We agree that it is not possible to estimate the overall prevalence
of significant traumatic brain injury in head injury patients presenting
after 24 hours of injury from our study. However, our study shows that in
patients that undergo CT imaging the prevalence of significant injury is
similar in patients presenting within and after 24 hours of injury. The
yield from the CT scans performed suggests a similar relation between risk
of pathological finding and clinician behaviour, but agree the denominator
for those attending late would be needed to confirm this. Our key finding
is that absence of NICE guideline indications may not reliably exclude
significant injuries in patients presenting after 24 hours of injury.

We agree with Richard Body (Associate Editor) when he opines that the
findings of our study probably call for further research. A prospective
study that evaluates all head injured patients presenting late and
identifies the risk factors that predict significant injury would inform
clinician gestalt. This, in turn, would likely reduce the risk of missing
significant injuries in what appears to an important sub-group.

1. Marincowitz C, Smith CM, Townend W. The risk of intra-cranial
haemorrhage in those presenting late to the ED following a head injury: a
systematic review. Systematic reviews 2015;4(1):165.

Conflict of Interest:

I thank the authors for highlighting an ongoing concern I have with
NICE head injury guidance - namely that the guidance is based on studies
of acute head injuries presenting soon after injury and doesn't take
delayed presentations into account.
However my concern would be the reverse of their own as I feel if we
adhered to NICE guidance in patients presenting after 24 hours we would be
performing large numbers of unnece...

I thank the authors for highlighting an ongoing concern I have with
NICE head injury guidance - namely that the guidance is based on studies
of acute head injuries presenting soon after injury and doesn't take
delayed presentations into account.
However my concern would be the reverse of their own as I feel if we
adhered to NICE guidance in patients presenting after 24 hours we would be
performing large numbers of unnecessary investigations for very low yield.

I cannot help but feel that the entire premise of this paper and
conclusions reached are incorrect simply because they look at the wrong
cohort.

The paper examines those patients who underwent a CT of their head
and compares between the delayed presentation and early presentation
(greater and less than 24 hours respectively) and those that had a NICE
indication and those that didn't.

This is easy data to collect retrospectively and analyse but not the
most appropriate.

What is far more valuable is to know what happened to ALL the
patients presenting post head injury - not just those who were selected
for a CT. This is far more challenging data to collect due to coding
issues, quality of note keeping and the vastly higher number of patients
involved.

Conclusions such as clinicians being aware that 'application of NICE
guidance to those presenting >24hrs misses a high proportion of
injuries, clinicians appear aware of this and so are more likely to
request a CT even though no NICE indication is present' appear invalid. We
do not know what proportion of patients with a head injury presented
before and after 24 hours we only know those that had a CT performed. The
clinicians themselves had already selected a group based upon a
combination of NICE guidance and gestalt.

We can best evaluate the sensitivity and specificity of the NICE
guidelines for patients presenting after 24 hours by looking at the
unselected head injured patients presenting to the ED. If we evaluate
those who a clinician had seen and ordered a CT head on then all we can
really comment on is the positive and negative predictive value of the
guidelines in the ED clinician selected patient (which one would hope to
be an inherently higher disease prevalence group).

Whilst I agree that there is somewhat of a lacuna in the guidance
when it comes to delayed presentations of head injuries, clinical gestalt
is key rather than the use of NICE guidance.
The data presented does not in my view show a distinct risk profile for
those presenting after 24 hours with a head injury (as stated in the
conclusions), but instead demonstrates that the negative predictive value
of the 2007 NICE Head Injury guidelines in patients at Hull Royal
Infirmary who had a CT after presenting >24 hours after head injury to
be lower than in those presenting <24 hours after head injury. (7.7%
compared with 9.9%).

Conflict of Interest:

Pocock et al present fascinating insight to the challenges of the pre
-hospital environment for undertaking clinical trials (Human factors in
pre hospital research: lessons from the PARAMEDIC trial Pocock H, et al,
Emerg Med J 2016; 33: 562-568) which explain the lack of clear strategies
of the implementation of research protocol on this issue. The need for
strong relationships between teams brings into focus the potenti...

Pocock et al present fascinating insight to the challenges of the pre
-hospital environment for undertaking clinical trials (Human factors in
pre hospital research: lessons from the PARAMEDIC trial Pocock H, et al,
Emerg Med J 2016; 33: 562-568) which explain the lack of clear strategies
of the implementation of research protocol on this issue. The need for
strong relationships between teams brings into focus the potential to
extend this study to incorporate the actions of the first person on the
scene. Recognizing the need for 'normalization' of participation in trails
reflects a similar challenge to find bystander participants to help us
understand lay responder behaviour. Both aspects chime with findings of
research from an earlier point in the pre-hospital care process studied by
the British Red Cross and published in this journal in 2013 (Can first aid
training encourage individuals' propensity to act in an emergency
situation? Oliver E, et al, Emerg Med J 2013 pp.emermed-2012).

The Utstein Formula for Survival (The Formula for Survival in
Resuscitation, Soreide E et al, Resuscitation. 84:1487-1493, 2013) models
the value of medical science as a multiplicative relationship with
educational efficiency and local implementation, yet the volume of
research around how to make education for bystanders effective in order to
guarantee effective intervention is scant. An analysis of the 2015
International Liaison Committee on Resuscitation's 2015 guidelines
identified a lack of research into how best to plan and prepare and how to
recognize an emergency. These crucial gaps need to be filled if bystander
interventions are to be adequate enough for EMS teams to improve their
chances of saving lives.

New guidelines produced by the International Federation of the Red
Cross (International first aid and resuscitation guidelines 2016) include
a new chapter on Education reflecting work to date and incorporating
evidence for improving educational approaches and strategies. Poignant,
though, is the lack of an internationally agreed definition and metric for
effective first aid education. We continue to be severely challenged to
understand the outcome behaviours of lay responders who have been trained
to help and their interaction with the ill or injured. How do we know if
first aid education has been effective? What do we mean by effective
education? And how could we measure it consistently? How do we get a clear
picture of how attitudes and behaviours are related to acquisition of
skills and knowledge?

The volume of medical science relating to emergency response is
substantial. Does such dominance limit discussion on educational
efficiency and local implementation of lay responder strategies? We urge
support for such studies to develop these aspects of survival.

Conflict of Interest:

The comprehensive review by Ramlakhan et al of the effectiveness of
primary care services located within EDs draws mixed conclusions. Whilst
initial efficiency savings were identified (both in terms of GP resource
utilisation and overall cost) and subsequent hospital admission and
referrals appeared reduced, other outcomes proved disappointing or at best
equivocal including length of stay, waiting time and patient satisfa...

The comprehensive review by Ramlakhan et al of the effectiveness of
primary care services located within EDs draws mixed conclusions. Whilst
initial efficiency savings were identified (both in terms of GP resource
utilisation and overall cost) and subsequent hospital admission and
referrals appeared reduced, other outcomes proved disappointing or at best
equivocal including length of stay, waiting time and patient satisfaction.

Given the ongoing critical performance challenges faced by hospitals,
that not only derive from increasing volumes of attendance (whether
through provider-induced demand or otherwise) but also the effect
consequently imposed by inefficiencies and the internal degradation of
pathways, Emergency Departments need to do something radical. The crucial
importance of optimising hospital productivity legitimises the use of
novel streaming services that aim both to minimise the effect on the
hospital of low acuity patients and, specifically, to de-bulk ED Majors
attendance. If a streaming service is to be used, then the same article's
review by Abdulwahid et al identifies the positive impact of senior doctor
assessment at triage. In contrast to the mainly senior ED clinicians that
were reviewed in this paper, our own belief is that senior GPs have a
better chance of deflecting or re-directing potential admissions, not
least because of clinician awareness of community-based options for care.

The introduction of a streaming service to the front door of
Leicester Royal Infirmary (Europe's busiest ED) has aimed to achieve
success using immediate clinical assessment by a senior GP on arrival
followed by rapid assessment using 3 other streaming GPs. In a 6 month
period this small team managed to treat or redirect 19% of all day time
walk in patients that presented (equating to 16,094 patients per year not
entering hospital) while only admitting 5% of patients to ED Majors. This
scale of success in streaming can result in significant performance
advantage for the hospital, both effectively redirecting patients that
could be cared for elsewhere and optimising use of internal pathways and
thereby improving efficiencies.

I read with interest your recent case report of a perilunate
dislocation. This case highlights the importance of careful assessment of
often complex wrist X-rays.
As a small point, I would however disagree that the 'spilled teacup sign'
is a sign of a perilunate dislocation. This sign is a radiological sign of
a lunate rather than perilunate dislocation.
The key to distinguishing between between both is to first determine...

I read with interest your recent case report of a perilunate
dislocation. This case highlights the importance of careful assessment of
often complex wrist X-rays.
As a small point, I would however disagree that the 'spilled teacup sign'
is a sign of a perilunate dislocation. This sign is a radiological sign of
a lunate rather than perilunate dislocation.
The key to distinguishing between between both is to first determine what
is centred over the radius on the lateral view.
If the capitate is centred over the radius and the lunate is tilted out
with the 'spilled teacup' sign, a lunate dislocation is diagnosed.
If the lunate centres over the distal radius and the capitate is dorsal, a
perilunate dislocation is diagnosed, as your case illustrates.

Conflict of Interest:

Murphy-Jones and Timmons described paramedics' experiences of end-of-
life decision making with regard to nursing home residents, including the
challenges faced by paramedics when patients lacked decision making
capacity and the resultant stress from uncertainty about appropriate
treatments. [1] Among the solutions suggested, an essential,
straightforward and well-tested tool for the perplexed paramedic was not
available...

Murphy-Jones and Timmons described paramedics' experiences of end-of-
life decision making with regard to nursing home residents, including the
challenges faced by paramedics when patients lacked decision making
capacity and the resultant stress from uncertainty about appropriate
treatments. [1] Among the solutions suggested, an essential,
straightforward and well-tested tool for the perplexed paramedic was not
available to EMTs in London. Emergency medical providers in the United
States report that that Physicians Orders for Life-Sustaining Treatment
(POLST) Paradigm forms both increase the likelihood that the wishes of
patients with advanced illness and frailty will be honored and decrease
the family and health professional angst of end-of-life decision-making in
moments of crisis. POLST orders have been shown to be effective in
providing clear instructions to emergency medical providers and in making
sure patient wishes at end-of-life are honored -- whether for comfort care
or more intensive treatment. [2] [3] [4]
The POLST Paradigm is an approach to end-of-life planning for those with
advanced illness through a process of shared decision-making between a
patient and his/her health care professional. As a result of these
conversations, patient wishes are documented in a POLST form, [5] which
translates the shared decisions into actionable medical orders, indicating
a patient's wishes regarding treatments that are commonly used in a
medical crisis. As a medical order, emergency personnel - such as
paramedics, EMTs, and emergency physicians - must follow these orders in
the absence of other information. The orders address preferences regarding
cardiopulmonary resuscitation (CPR), other medical interventions such as
intubation and mechanical ventilation, and artificially administered
nutrition. The orders are signed by a physician (and is some jurisdictions
a nurse practitioner or physician assistant) with the concurrence of the
patient or legally recognized decision maker. The POLST form is
distinctive, often brightly colored and can be displayed prominently so
that it can be easily identified by the emergency medical personnel.
The POLST Paradigm has been successfully implemented in the vast majority
of states in the US, and is being adopted in a growing number of
countries. We encourage health systems to adopt and emergency medical
providers who care for patients at the end-of-life to learn more about the
POLST Paradigm and how it can provide medical orders and direction when an
emergent situation faces providers, patients and families. [6]

Arthur R. Derse, MD, JD
Terri A. Schmidt, MD
Susan W. Tolle, MD

[1] Murphy-Jones G, Timmons. Paramedics' experiences of end-of-life
care decision making with regard to nursing home residents: an exploration
of influential issues and factors. ] doi:10.1136/emermed-2015-205405